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PHARYNGO -TONSILLITIS
ETIOLOGY
Viral cau se:
Rhin o viru s( com m on cold)( 60 %)
Enterovirus,Influenza virus,Para-influenza virus.
Adenovirus,
Special: HIV, Cytomegalovirus, Coxsackievirus, Herpes simplex,
Ebs tein -barr viru s, Bird flu?).
Bact e r ia l caus e :
Group A B-hemolytic streptococci (GABHS), 15-30% > 3yr
C, diptheriae, Hemophilus influenzae, N. meningitides.
Special; Gonococcus , A. h emolyticu m, an d Mycoplasm a pn eum oniae
Diagnosis of viral is mainly clinical
Blood cou n t, E SR a n d CRP- low predictive valu e
T h r o a t c u l t u r e
Gold standard for diagnosing streptococcal pharyngit is cannot
differentiate between car riers an d ca se
Negative throat culture result has a very high negative predictive
valu e for GABHS p h ar yngitis
Major drawba ck - lag time of 18 -48 h ou rs
Not curren tly pra cticed in m ost centers in Ind ia !
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In ch i ld ren wit h n o pen ic i ll in a l l e rgy
An tibiotic (rou te) da ys Ch ildr en
(30kg
Pen icillin V (ora l) (10 d) 25 0 m g BID 50 0 m g TID
Am oxycillin (ora l) (10 d) 40 m g/ kg/ da y 250 m g TID
Benzat h ine pen icillin G (IM) (single dose) 6 lakh u n its 1.2 m illion
un i t s
In ch ildren with pen icillin allergy (n on type 1)
An tibiotic (rou te) (da ys) Ch ildr en (
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Management protoclol
Examine eye/ ear / nose / body
Conjunctivitis / coryza,
diarrhea, hoarseness/ cough
Purulent/ patches/ toxic /
tender L. nodes
- Viral > -
Symptomatics (3-4 d)
Bacterial antibiotics
before / after culture
Responds No response
Culture / RADT Response Follow
up-ve
+ve
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SINUSITIS
Two types of settings
Prolonged, u pper respiratory signs / sympt oms > 10-14 days.
Severe u pper r espiratory signs/ symp toms ( fever >102 d egree F,
Facial swelling and pain)
Class i f ica t ion o f S inu s i t i s
Acu te infection 14/ 102degree F, pu ru lent discha rge , s ick ch ild
Su bacu te : 30 -90 days
Recu rren t: < 30 d ays; relap se after 10 da ys
Chron ic: > 90 da ys.
De v e lo p m e n t o f s in u s e s
Development begins complete
development
Maxillar y an d eth m oid
s i n u s e s
10 th week POG At birth
Sph enoid sinu s 3Yrs 8 yrs
Fronta l s inus 7- 8 yrs Ear ly teens
Pred ispos ing fac t o rs
Viral URI
Allergic rh initis an d n as al polyps
Nas al foreign body
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Adenoidal hypertrophy
Nas ogas tric tu be
Cleft palate
GERD
Mucociliar y d isord ers
PC D
CF
Karta geners s ynd rome
Imm u n odeficiency stat u s
Dental infections
Co m m o n Pa t h o ge n s
Acute an d Su bacu te s inu si t is
s t rept . Pneu moniae
Non typeable H. influ enzae
Moraxella catarrhalis
Strept p yogens ( beta h em)
Chronic Sinusit is
Bacterial pathogens not well defined
Polymicrobial infection common
Alph a h emolytic strept, s tap h au reu s, CONS, Non t ypeable H
in fluen zae, Mora xella cat ar rh alis & An aer obic Bacter ia
Guidelines for Radiological Diagnosis
X- rays th erefore not n eeded in m ost.
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Clinical correlation is good.
X- rays recommended if:
Recur ren t
Complications Unclear diagnosis
M a na ge m e n t M e d i c a l
An tibiotics Main s ta y :
Am oxycillin (40 m g/ kg/ da y)
Cefuroxime
Co - am oxy- clavu lan ic a cid can be s econd lin e if initial ch oice
was a m oxicillin
Macrolides e.g. Azith rom ycin
Select an y of th ese bas ed on cost an d sa fety
If severe disea se or failu re to firs t lin e dr u gs
Paren tera l ceftriaxone/ cefotaxim e then m ay switch to oral
cefpodoxime
Treat for 10 to 14 days or 1 week beyond symptom resolution,
whichever is lat er.
In case of persistent non response ( already used 1st and 2nd l ine
drugs)
Ima ging an d s inu s a spira t ion could be done.
Adjuvant th erapies :
lim ited da ta
not recomm ended
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ACUTE OTITIS MEDIA
Sign s of acu te otitis m edia
Erythema
Fluid
Impaired mobility
Acut e symptom s
Man agem en t of AOM- Und er 2 yrs
An algesia pa ra cetam ol in good doses a s good a s ibu pr ofen
Decon gesta n ts n o role
An tibiotics in d ivided d oses for 10 da ys
ch oices, first line Am oxycillin / co-am oxycla v
second line * second generation cephalosporins e.g.
cefaclor, cefu roxime
co-am oxyclav- if n ot u sed ear lier.
Man agemen t of AOM in > 2 vr old ch ildr en
An algesics --> ma in sta y of trea tm ent
Decongesta n ts h ave qu estiona ble role
Antibiotics
No ur gen cy to sta rt a nt ibiotics u nlike a
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P r o t o c o l fo r m a n a g in g Ac . Ot i t i s m e d i a
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CROUP
? CHARACTERISTICS :
Acu te on set
Fever, ru n n ing nos e an d cou gh - in fective etiology - likely to be
upper airway
ch an ged cough ch ar act er- likely to be involving lar ynx.
Hence a n acu te u pper airway in fectionlaryn git is +.
GRADING SEVERITY OF CROUP
Mild Moderate Severe
General
appearance
Happy, feeds
well, interestedin su r rou ndings
Fussay bu t
interactive,comforted by
paren t s
Restless,
agitated, alteredsensor ium
Str idor Stridor oncoughing &
crying, No
stridor at rest
Stridor at rest ,worsening with
agitation
Stridor at rest ,worsening with
agitation
Respiratory
distress
No distress Tach ypnoea,
tachycardia &chest re t rac t ions
Marked
tachycardia withchest re t rac t ions
Oxygena tion >92% in room
a ir
>92% in room
a ir
92%
An tibiot ics No ro le No role No role
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Managem en t o f mi ld c roup
Requires no t rea tm ent
Symp tomat ic t rea tmen t :
Fever - u se a nt ipyretics to d ecrease oxygen requ iremen t.
If bothersome coryza- 1st generation anti-histaminics may be
u s e d
Norma l saline n as al drops - if na sa l blockad e.
Grey areas :
Cold a i r inh ala t ion / ba th room s teaming may help
A single oral dose of prednisolone/ dexameth as one p referred by
few to decrease the parental stress as well as the r isk of return
to the m edical care.
PARENTAL ADVICE :
Parents to be informed that croup generally gets more severe at
nights .
To look ou t for increa sing s everity man ifested by
increa sing str idor,
increasing breathing difficulty , and
child gettin g in creas ingly agita ted with refu sa l of feeds
To come back to medical assistance if severity increases
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INVESTIGATING CROUP:
S Crou p is a clin ical diagnosis. In vestigations n ot requ ired in a typical
croup.
In a child with airway obstruction, neck radiographs or blood tests
cause anxiety which may precipitate further distress and obstruction.
X -ra y AP view of th e s oft t iss u e of n eck
if don e - reveals a ta pered n ar rowin g ( st eeple sign ) of th e
su bglot t ic t rachea ins tead of norma l shou ldered appeara nce .
sh ould be d one if:
- poor respons e to t rea tm ent
- poss ibility of Retroph ar yngeal abs cess
o toxic with h igh fever
o difficu lty in s wallowin g, dr oolin g of sa liva
o
ma lnou rished child / s ta ph ylococcal skin st igma ta
MODERATE CROUP
Increase in severity is not considered by mere increase in the
intensity of the sound , but by increasing degree of obstruction. Croup
can be called as modera te when child develops str idor at res t .
M a n a g e m e n t :
Observation for up to 4 h ours
st eroid -> if n ot given before , u se a dose of oral / n ebu lized/
IM
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Repeat dose of nebulized steroid - if previous dose > 12 hours
back.
Nebu lized Adren alin e :
Used if symp toms are in creasing . -> Repeated if
clinically indicated
Routinely available adrenaline as effective as racemic
form.
If symp toma tic at th e end of 4 h rs, h e can be discha rged.
STEROID AND ADRENALINE DOSE
Ste ro ids
Repeated doses of 2 m g neb u lized bu deson ide 12 h r X 48 h rs
Ora l an d IM dexam eih as one is equ ally efficacious
Oral corticosteroids are preferred for their ease
Doses-> dexam ethas one 0 .15- 0 .30 m g/ kg, prednisolone 1 - 2 mg /
k g
Adrenal ine
Adrenaline is used in severe cases and those poorly responsive to
steroids
0.5 m l/ kg of 1:1000 dilu tion t o maximu m of 5 m l.
Need for repeated doses sh ould alert the n eed for int u bation / PICU
carep
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STE ROIDS IN CROUP
Th e us e of steroids h as been a ss ociated with ,
Redu ced average length of sta y in th e emergency
Decreas e in th e nu m ber of adr ena lin e nebu lization n eeded.
Redu ced need for en dotrach eal int u bat ion.
If requ ired, th e du rat ion of in tu ba tion is d ecreased.
Current evidence more strong for its efficacy in moderate to severe
croup.
MANAGEMENT OF SEVERE CROUP
Continu e oxygen a s requ ired.
Admit.
Continu e nebu lized adr ena lin e as frequen tly as n eeded,
if requ ired > 2 h rly, cons ider s h ifting to PICU.
Steroids to be continu ed.
INTUBATION
if airway obstru ction/ work of breath in g is worsening, then one h as to
consider intubation and venti lat ion.
Experienced hands only , as intubation is difficult and if fails the
pat ient m ay be worse , ? Rapid sequ ence in tu bat ion.
u se a tu be ha lf s ize sm al ler tha n opt ima l.
Trach eostomy is t h e las t option
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Typical paroxysm :
A series of rapid, forced expirations (usually 5-10), followed by
gasp ing in h alat ion , lead in g to th e typical wh oop
Cyanosis, bulging eyes, protrusion of the tongue, salivation,
lacrimation an d distens ion of th e neck veins occur s.
post-tussive vomiting is common.
Several t imes per hou r- dur ing both da y and night .
Triggered by yawn ing, s n eezin g or ph ysical exertion. In between
th e paroxysm s, th e patient is u su ally well.
DIGNOSIS CONFIRMATION
CBC
Abs olu te lymph ocyte cou n t > 10,000/ micro It
ALC a bove a ge specific m ean h as 70 % sen sitivity.
Norma l coun t does not exclu de pertu ss is
Neona tes ma y have mu ch h igher coun ts
CXR not sensitive or specific
Role of cu ltu res - not of pra ctical im porta n ce
Serology an d PCR not recom men ded routinely
Diagn osis u su ally clinical aided b y CBC.
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TREATMENT
Antibiotics
reduce transmissibil i ty
ma y redu ce sympt oms if given in 1st week.
lim ited r ole as u su ally diagn osed later .
Avoidance of cough provoking factors.
Humidified oxygen and assisted ventilation in seriously ill, usually
infants.
Dose an d du ra t ion S ta tus
Eryth romycin 40-59 mg/ kg/ day q 6
hr ly x 14 da ys
Side effects
dura t ion / adherence,
not > 1 month
Cla r ith romycin 15mg/ kg/ day
Q 12 h r ly x 7 da ys
Expensive. Drug
interaction, not > 1
month
Azith rom ycin (DOC) 6 m o n t h s : 1 0 m g/ k g
on d a y 1 a n d 5 m g / k gday 2-5
Cheap, no drug
interaction can be
given >1 m ont h
Cotrimoxazole 8 m g/ kg of TMP Q 12
h rly x 14 da ys
Intolerant / CI of
macrolides
TRE ATMENT- S UPPOR TIVE
One m ay try bron chodialators/ cough seda tives an d individu alise as
per response
Routinely none of the following are of any benefit
Antihistaminics
Steroids Salbutamol
Pertussis immunoglobulin
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DIPHTHERIA
CRITERIA TO pfcNOSE DIPHTHERIA
Sore throat with m emb ran e in ton sillopha ryngeal area
Fever, hoarsen ess, bar king cough, str idor, mem bra ne over pha rynx
an d la rynx
Sero- sanguinous nasal d ischarge , crus ts and a whi te membrane
on s e p tu m .
Late pres enta tion s : us u ally n o visible mem bra n e
Palata l or bu lbar palsy
myocardit is with prior s ore thr oat
Acu te polyneu ropath y with or with out prior s ore throat .
May occu r even in previous ly im m u n ized
CONFIR MING DIPHTHE RIA
Smear and culture of the membrane or scrapping below the
m e m b r a n e
Sta in with Neiss er or Albert st ain
MANAGEMENT OF DIPHTH ER IA
Hospitalization in in fectiou s diseas e facility
Droplet isolation till thr ee cons ecu tive da ily cultu res a re n egative
Start treatment without waiting for microbiologic culture confirmation
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Comp onents of therap y
Diph th eria a n titoxin (DAT), m ost cru cial
Antibiotics
Supportive care
Man agemen t of complication s
Trea tm en t - DAT
Always ad minister tes t d ose
If allergic des en sitize
Fu ll dos e given IV at one tim e, dilu ted in NS (1;20 ), ra te of m l/ m inu te
Limited a vaila bility at ID hos pita ls
Serum s ickn ess in 1 0% pat ients
Type Tota l dose in
u n i t sNasa l 10,00 0 20,00 0
Laryngeal / ph aryngeal 20,000 40,000
Tons illar 15 ,00 0 25 ,00 0
Combined types / delayed diagn osis 40,00 0 60,00 0
Severe diseas e* 80,00 0 100 ,000
Carr ier / conta ct Not required
* Extens ive disease/ more than 3 days dura t ion / neck
edema/ t achycard ia / collapse / b rea th lessness .
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Tr ea t m e n t c on t i n u e d
An tibiotics (pen icillin G/ Procaine pen icillin / Eryth rom ycin for 14
days)
Strict bed res t for 2 - 3 weeks
Adequate nutri t ion and hydration
Steroids not recommen ded
Carni t ine 10 0 m g/ kg/ day BD for 4 doses ma y help prevent ing
myocarditis.
# u se fu lness if given lat e in the disea se???
Airway ma in taina nce in th ose ha ving obstr u ction
# Intu bat ion/ t racheotomy, oxygen therapy
Complete immunization on recovery.
BRONCHIOLITIS
FEATURES:
You n g, well lookin g in fa n t
Tach ypnea ++
Tachycardia++
Saturating well
Bilateral scattered wheeze
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GRADING BR ONCHIOLITIS
MILD MODERATE SEVERE
F e e d i n gabi l i ty
NormalAbility to
feed
Appea r sh ort ofBrea th dur ing
feeding
May be relu ctan t oru n ab le to feed
Respira tory
d is t ress
Little or n o
resp
distress
Moderat e d istress
with
some chest
Wall retra ction s
an d n as al flaring.
Severe distr ess with
marked chest wallre t rac t ions , na sal
flaring an d grun tin g
Can ha ve frequent
an d p rolonged
a p n e a s .
Saturation Saturation>92%
Satu ration 9 2%
IV flu ids
Cardiorespiratory
monitoring
ABG/ CXR
Assess need for
ventilatory
su pport/ ICU care
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DIFF ER ENTIAL DIAGNOSIS :
Pneumonia
GERD with a sp iration
Foreign b ody
Congen ital heart d iseas e
Broncho-pulmonary dysplasia
Congenital an oma lies like vascu lar r ing
BRONCHIOLITIS
- R is k f a c t o r s f o r in c r e a s e d s e v e r i t y a n d h o s p i t a l i za t i o n .
Infants in day care
Exposure to pa ssive sm oke
Crowding in t h e hou seh old
Infants you nger tha n 2-3 mont hs
Prema tu re birth s < 3437 weeks
Con genital heart diseas e
Chronic lung disease l ike CF, Recurrent aspiration, BPD,
congenital malformations etc.
Immunodeficiency
Hypoxia
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INDICATIONS FOR HOSPITALIZATION
In fan t s you nger than 3 m onths
Oxygen s atu rat ion < 92%
Resp Rate > 70/ min
ILL appearing child
In fan ts with one or m ore risk factors m entioned b efore are likely to
ha ve a s evere cou rse an d m erit ad miss ion.
INVESTIGATIONS :
Bron ch iolitis is a clin ical diagn osis
In vestigations cont ribu te very little
CXR ma y be in dicat ed in
severe respiratory distress or
in a case of diagnostic u n certainty
Atypical course
Chest X-ray
often reveals bilateral hyperinflation findings like segmental
atelectas is m ay be seen some times.
Blood tests do not contribut e
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MANAGEMENT:
Non con t rovers ia l Cont rovers ia l
Oxygen
IV flu ids
Fever man agement
Adren alin e n ebu lization
Bronchodilators
Steroids
Antibiotics
Lim i ted u se- n o t be ing d iscu ssed
Palavizumab and Ribavarin
FEEDING AND FLUIDS:
Oral feedin g
May be cont inu ed in infan ts with n o more than moderate
respiratory difficulty. (respiratory rate < 80 breaths per minute,
some ch est wall retraction, Sp02 . 92% +/ - oxygen)
Nas ogas tric tu be feedin g
Generally reserved for th e recovery pha se b ecau se;
# NG tubes blocks one nostril- increased airway
resistan ce, in creased work of breat hing.
# Feed in th e stoma ch - in creased th e r isk of reflu x an d
asp ira t ion a s compresses th e diaph ragm.
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INTRAVENOUS FLUIDS:
Administered when there is moderate to severe or severe
respiratory difficulty.
(marked chest wall retractions, nasal flaring, expiratory
gru nt ing, ma rked ta chypnoea (.80/ min), apn oeic episodes, or
visible tiring during feeding.
Considerable variation in the intravenous hydration strategies
recommended.
Norma l genera l ma in tena n ce IV flu ids to be u sed.
OXYGEN:
Common sen se dictates i ts u se to overcome h ypoxemia
In genera l, aim to ma in tain Sp0 2 > 92%
Can accept 90% to 92% Sp02, if the child is not distressed and is
feeding well
BRONCHODILATORS :
There is no role for routine bronchodilators in bronchiolitis as they
do not;
imp rove oxygen s atu rat ion.
affect rate or duration of hospitalization.
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A trial of n ebu lised bron ch odilat or can be given in :
Older in fan t ( > 6 m ont h s) with wheeze.
Those with a stron g history of atopy, fu rth er thera py continu ed
if th ere is a objective impr ovemen t.
STEROIDS:
Multiple studies have failed to demonstrate any clear efficacy of
corticost eroids in viral br onch iolitis
NEBULISED ADRENALINE
Little support from randomized clinical trials for its use in all
children with m oderate/ severe diseas e
Improvement in respiratory symptoms across studies
incons isten t an d sh ort lived.
May u se n ebu lised Adren aline as a potential rescue m edication for
th ose wh o are to be ad mitted.
Dose varies between 0.01 ml/ kg to 0.3 ml/ kg per dose of 1: 1000
solut ion.
ANTIBIOTICS:
RCTs failed to demonstrate any benefit in hospitalized infants with
bronchiolitis.
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Th e on ly role of a n tibiotics is
complicated bronchiolitis where a secondary bacterial infection
is s u spected.
Th is is rar e, bu t n ot eas ily exclu ded in a sick infan t with fever,
toxicity an d s ign ifican t opa cities on th e ches t X-ray
SEDATION
No sa fe seda tion ; seda tives s h ould b e avoided
Irr itab ility ma y be a s ign of Hypoxia
Sedatives can decrea se th e oxygen ation a s well as give false sen se
of relief.
Attemp ts to comfort th e child a s far a s p ossible
Fever con trol
Nasal clearing
Feeding
Non th reaten in g m an ner of oxygena tion/ neb u lisa tion
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VIRAL BRONCHIOLITIS
Mild bronchiolitis
Normal ability to
feed
Little/no resp.
distress
Not hypoxemic
Moderatebronchiolitis
Moderate resp.distress
Mild hypoxemia brief apnea
short of breath
Severe bronchiolitis
Severe resp.
distress apnoeic episodes
hypoxemic
Looking tired
Cant feed
Does not needinvestigations
Home treatment
Admit
Humidified O2
to maintain Sa2above 92%
IV fluids
Adrenaline trial
Observe for
deterioration
Admit ICU care
O2 to maintain
Sa2 above 92%
IV fluids
Adrenaline trialcardio
respiratorymonitoring
A BG, CXR Assess need for
ventilatorysupport/ ICU
care
Improvement
Decrease O2
(guided by SaO2)
Re-establishfeeding
Discharge whendistressdecreased and
feeding well
Deterioration
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PNEUMONIA
TACHYPNEA
Most Consistent Clinical sign of pneumonia
Ag e R e s p i r a t o r y r a t e (b r e a t h s / m i n )
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Chi ld wi th cough , rap id an d d i fficu lt b rea t h ing
Tachypnoea
A sensitive and specific tool - 66% approx.
as good or bet ter then au scu lta t ion for pneu monia
Any clinician therefore must use this merely as a beginning step
(Tria ge s ign )
An d t h en u se a ll th eir clin ical sk ills for th e fina l con clus ion
Remember several other cl inical si tuations that cause radia breathing
e,g,
Respiratory cau ses: Asth m a / Bronchiolites / WALRI
Non respiratory causes: metabolic acidosis, CHF, rasied ICT
Pneumonia any cause
WALRI, Asthma,LTB,
Nonrespiratory
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Differe n t ia l d iagnosis
First ru le ou t non - resp iratory cau ses for tachypnoea,
Th en, t h e No- pu lmon ary cau ses a re ru led out cl inically.
In this setting of child with cough, rapid and difficult breathing, now
th e l ikelih oods are;
Pneu mon ia comp lication s
Bronchiolitis
Wh eeze as sociated with lower res pirat ory tract infection s
Asthma
Croup
Child wit h Cough, Rapid , Difficul t bre at h ing
Cons ider bron ch io li t i s i f :
Age 1 m onth 2 years
Presence of u pper res piratorycatar rh
Progress ive in creas e in r esp.distress (tach pn oea, retractions )
Wheeze crackles Clin ical an d ra diological evidence of
hyperinflation
Cons ide r a s th m a i f :
Recurrent episode,3 or more
Afebr ile epis odes
Wheeze
Good response to bronchodilator
Hyperinflation
Fam ily / person al history of atopyy
Cons ide r wheeze as soc . w ith LRTI(WLRI) if :
Recur rent episodes of distressu nd er 3 years of age
Progress ive in creas e in r esp.distress (tach ypnoea, retractions )
Wheeze crackles
Clinical an d ra diological evidence ofhyperinflation
No family or personal history ofatopy
Cons ider laryngo t rac h eo-bron ch ii t is Croup if :
Hoarseness of voice and barking/bra ssy of cough
Stridor
Mild t o ma rked respiratory distress
Sonorous rhonchi
Fever usually mild or spiking(tracheitis, rate)
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Can v i ra l LRTI o r bac t e r ia l pneu m on ia be c lin ica l ly d i s t in gu ished ?
May be d ifficu lt as th e investigat ion s do n ot con firm etiology
Advantage of using the suggested methodology - decreases the
confoun ders to viral pn eum onia alone ra ter th an broad ARI.
Com m un i ty acqu i r ed Pn eum on ia (CAP)
CAP is an acute infection of the pulmonary parenchyma in a
previously healthy child, outside of a hospital setting.
not have been hospital ized within 14 days prior to the onset of
symptoms, or
h as b een h ospitalized less th an 4 da ys prior to ons et of sympt oms.
I t exc ludes
Ch ild with im m u n e-deficien cy
Severe Malnutrition
Post m easles state
Ventilator as soc pneu mon ia / Nosocom ial sp read
Recurrent pneu monias
DIAGNOSIS RADIOLOGICAL
Do all pa tien ts reqiure a ch est ra diograph ?
NO
Not a ll CAP, pa rticu larly if on dom iciliary trea tm en t
Few-Yes,
If s ever ely ill
If comp licat ion su sp ected (for exam ple, pleura l effu sion)
Ambiguous Clinical features.
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MICROBIOGICAL
Not recom men ded rou tin ely
Takes long t im e an d h ence h as limited u ti lity
Spu tu m cultu res / cou gh swabs ha ve relatively poor reliability
Invas ive meth ods can n ot be ju stified for routine pn eu mon ias .
R ole o f pu l se oxym e t ry , a cu t e phase r eac t an t s
TLC,DLC,CRP are not diagnostic but may be useful to monitor the
response to t rea tmen t .
Pulse oxymetry is a good tool for assessing the severity and
m onitorin g respons e in th ose with severe disease.
AGE RELATED PATHOGENS INVOLVED IN COMMUNITY
ACQUIRE D P NEUMONIA
0 3 m ont h s Gram n egative, strept o. Pyogenes,
Chlamydia, viruses
3 mon th s 5 years Strept . Pneu mon iae, H.influ enze,
s tap aureus , v i ruses , mycoplasma
p n e u .
> 5 year s Mycoplas ma pn eum oniae, str .
pn eum oniae . Stap. Au reus , viru ses ,
str p. Pyogens .
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Reliabi l i ty of predic t ing a specia l e t io logical agent based
on c l in i ca l fea tu re s and / o r r ad iography
Gen era lly POOR.
ONE E XCEPTION STAPH
More like ly if
very ra pid pr ogress ion
skin lesions, infected scabies
PE / p n e u m ot h o ra x / e m p ye m a
? Post m eas les
SE VER ITY OF PNEUMONIA:
WHO classification is very simple and probably more useful from
management point of view.
Severe - tachypn oea with accessory mu scles in a ction - lower ches t
indrawing
Very severewith additional features like
Altered sen sorium
Cyanosis
severe gru nt
in termit tent apnea
difficu lty in feedin g
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INDICATIONS FOR ADMISSION TO HOSPITAL
Sa02 < 92%
Marked tach ypnea, sa y 20+ breaths / min a bove the cu t off for the
age.
Difficulty in breathing
Intermit tent apn ea, gru nt ing
Not feedin g/ deh ydrated
Family not able to provide appropriate observation or supervision.
Failu re of OPD trea tm ent
TREATMENT OF C A P
D i s e a s e P n e u m o n i a
S e t t i n g Domicilliary
Age First lin e Second lin e Su sp ected stp h .Disease
Up t o 3 m o n t h s Usu ally severe, treated a s inp atients
3 m o n t h s t o 5
years
Am oxycillin Co-a m oxy clav
OR
Chloremphenicol
Cefuroxime
OR
Co-am oxy clav
OR Amoxycillin +Clox
5 y e a r s p l u s Am oxycillin Macr olide OR
Co-am oxy clav
OR
Chloremphenicol
Cefuroxime
OR
Co-am oxy clav
OR Amoxycillin +
Clox
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S e ve r e v e r y s e v e r e p n e u m o n i a
Treat a s in-pat ient
Age Firs t l in e Secon d l in e
0 -3 m o n t h s Inj. 3 rd gen cepha losporin s
cefotaxim e/ ceftr iaxon e Am inoglycoside (Gen ta l/
Amikacin)
In j co-am ox clav
+
Aminoglycoside
(Genta / Am ika cin )
3 m o n t h s 5years
Inj. Am picillin OR
Inj. Chloremphenicol OR
Inj Am picillin +
Inj. Chloremphenicol (
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NOT Cefixime because it lacks action against strep.
Pneumoniae
Fluoroquinolones are not recommended
Total 5-7 d ays
If on s econ d l in e, then treat for 7-10 d ays
If sta ph ylococcal d isea se.;
2 weeks if n o comp licat ion :
Else 4-6 weeks
INDICATIONS FOR TRANSFER TO PICU
Failu re to m ainta in Sa 02 > 92% in Fi02 > 0.6
Cyanosis
Shock
Rising respiratory and pulse rates with clinical evidence of
severe respiratory distress and exhaustion with or without
ra ised p aC02
recur rent a pn ea or slow irregular breath in g.
Excessive diaphoresis
HAP- Hospi ta l Acqu ired pn eu m on ia
Ea rly -ons et HAP an d VAP,
occurring within the first 4 days of hospitalization,
More likely du e to a n tibiotic sen sitive ba cteria.
Usu ally carry a b etter prognosis,
Lat e -on se t HAP an d VAP (5 d ays o r m ore )
More likely du e to mu ltidru g-resist an t (MDR) pa th ogen s,
Associated with increa sed pa tient morta lity an d m orbidity.
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RE CURR ENT P NEUMONIA
'At least two episodes of pneumonia occurring in one year or three
epis odes over a n y period of time.'
Recurren t pn eum onia is a s ymptom of an u nder lying disease an d n ot
a d iagn osis in itself.
Ca u s e s i n c l u d e
Comm onest Asth m a (m is- diagnosis), Asp irat ion syndr omes
less comm on Congenital anom alies, FB, CVS sh u nts , TB, tum ors
Not infrequ en t CF, Im m u n odeficiency, ciliar y dyskines ia.
Key point s on history an d exam ina tion
Delayed cord fall - leu ko a dh esion d efects
History suggestive of aspiration (choking nasal regurgitation,
recurrent seizures)
Tem pora l relation of cough t o feeding or postu re
Fam ily or persona l h / o atopy noctu rn al cou gh, bronch odilator rel ief
Fam ily h/ o similar d isorder or consa ngu inity
Multiple m u ltifocal in fection s e.g. diarrh ea, pyoderm a, ea r infection s
Malab sorp tive stools
Contact history
Orophayrngeal examination
Clubbing
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Oth er feat u res of at opy e.g., flexu ra l derm at itis
Failu re to th rive, BCG scar , ton sil size
Pallor, gen a den opath y
Perforative otitis media
Cardiovas cular system
Respirat ory system .
KEY DIFF ER ENTIATION :
Upper an d lower resp i ra t o ry
s y m p t o m s
O n ly lo we r r e s p i r a t o r y s y m p t o m s
Asthma
Immunodeficiency
Ciliar y d yskines ia
CF
Aspiration syn drom es
Congenital a n oma lies
CVS sh un ts
FB
TB
Tumours
Sam e lobe Di ffe ren t lobes
Foreign b ody
Tuberculosis
Congenital anomaly
Aspiration
Asthma
C VS s h u n t
Mucociliar y d efects Immunodeficiencies
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Inves t iga t ions fo r t he cause o f b ronch iec ta s i s
The cau se rema ins u nkn own in 30-50% of pat ients .
Needed investigations are:
FO Bronch oscopy,
HRCT or bron chograph y
Seru m imm u n oglobu lin levels,
Gast ro esopha geal reflu x stu dies,
Test s for tu bercu losis a n d fun gal in fection s ABPA
Sweet chloride, an d
Ciliary's studies
In v e s t i ga t i o n s i n b r o n c h i e c t a s i s a r e 3 fo ld
A:- To as certain an d esta blish t h e diagnos is - HRCT or radiology.
B:- Pulmona ry Fu n ction Tests to access the fu n ctions capa city of
the lu ngs .
In vestigations in bron chiectas is
F i n d i n gs o n x -r a y o f c h e s t a r e n o n s p e c i fi c .
Rin g like den sities with clear cent re
Irregu lar ill-defin ed vascu lar m ar king or
Unequa l aera tion du e to atelectasis an d h yperinflation
H ig h r e s o l u t i o n c o m p u t e r i z e d t o m o gr a p h i c s c a n (H R CT ) o f c h e s t :
Very sensitive and non invasive method
Fin dings inclu de
Lin ear n on ta pering a irway
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Co- Am oxyclav / ceftriaxon e with or with ou t flu roqu in olones if
pseu domon al colonization is su spected l ike in CF.
Airway cleaning, bronchial lavage and hygiene with chest
physiotherapy to br ing ou t spu tu m is very importan t an d pru dent s hou ld
be promoted.
Presented with fever, ches t pa in ,
Expectoration: 6 weeks
Did n ot respond to broad sp ectrum an tibiotics
He had mild clubbing, bronchial breathing right infrascapular region
an d crepita tion s a ll over righ t side of ches t
Wha t a re t he d iagnos t ic poss ibi li t i e s?
Cau ses of lu n g abs cess
Most frequently a complication of bacterial pneumonia
Epecially th ose du e to sta ph ylococcus a u reu s,
Klebsiella p neu mon ia a n d
Pseudomonas
May develop in sequestration of lung tissue or in association with
foreign bodies, bron chial cyst s or st enos is.
Staphylococci lungs abscess are often multiple, while those
complicating aspiration are solitary.
May ru ptu re in to th e pleu ra l space leading to pyopnu emothrax
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Lung abscesses are frequently a complication of higher bacterial
pneumonia or obstruction due to retained FB or bronchial cyst ,
congenital anomaly like sequestration of lung tissue may also lead to
lu ng abscess .
Take Hom e Messages
Viral infections and non infectious causes of cough do not need
antibiotic therapy
Few situa tion s for em piric u se of an tibiotics.
Unwana nted u se does not prevent a su bsequent s econdary infect ion
in most s itu a t ions .
First line a n tibiotics a re s till effective an d d ru gs of ch oice.
Newer 3rd -4th generation antibiotics should be reserved for few non
responders .
All non responders a re not du e to a res is tan t bu g. Other caus es are as
important .
Ta k e h o m e m a s s a ge s
Children p resen tin g with fever, cou gh with n as al / ear discha rge
[Includes: acute nasopharyngit is , tonsil l iopahryngit is , s inusit is and
otitis media]
Majority are du e to vira l in fection s
An tibiotics do not p revent s econda ry bacter ial infection s
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Do throat swab cu ltu re / RADT in acu te tons illopha ryngit is , if
Exudates on tonsil lar surface, cervical node enlargement, absence of
conjuctival congestion or symptoms persist for > 3 days
Cons ider s in u sitis: if URTI pers ist beyon d 7 -10 d ays
Do otoscopy in all URTIs to diagnosis otitis media
An tibiotics in : GABHS ph ar yngitis, s inu sitis, severe otitis m edia or red
an d bu lging tymp an ic mem bran e
Us e firs t lin e a n tib iotics firs t, AMOXYCILLIN IS STILLL EFFCTIVE.
Ta k e h o m e m e s s a ge s :
Ch i l d r e n p r e s e n t i n g w it h fe v e r , c o u gh w i t h n o i s y br e a t h i n g
Common conditions: adenoidal hypertrophy, croup, pertussis ,
d iphther ia
Croup: comm only du e to viru ses, n o an tibiotics
Croup : single dose of system ic st eroids with epin eph rine SOS
Diphtheria: Isolate, start penicillin and ADS, give immunization on
follow up.
Pertussis: Macrolides with supportive care.
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Ta k e h o m e :
Ch i l d r e n p r e s e n t i n g w it h b r e a t h i n g d i ffi c u lt y
[Com m on cond i t i on s : Br onch i o li t i s , pn eum oni a , Br onch i ec t as i s ,
e m p y e m a a n d lu n g a b s ce s s ]
Bronchiolitis: viral infection,
Oxygen inhalation, IV fluids
Adren alin e tr ial
P n e u m o n i a :
Ass ess clinically, n o n eed for C-X ra y in every ch ild.
Am oxicillin dr u g of ch oice for am bu latory trea tm en t
For h ospitalized ch ildren : In j Am picillin / Chloram ph enicol or Co-
Amoxyclavulanic acid.
Add macrolides if suspecting atypical organisms
Children< 3 months: Third generation cephalosporins +
Aminoglycosides
E m p y e m a
Cloxacillin + Ceftraixone or Co- Amoxyclav